Amenorrhoea/oligomenorrhoea + PCOS Flashcards
What are the general causes of amenorrhoea?
Central
- Hypothalamic - stress, exercise, weight change, endocrine
- Pituitary - tumour
Peripheral
- Ovarian - congenital, genetic, autoimmune
- Acquired structural outflow issues (uncommon)
What is the definition of primary and secondary amenorrhoea?
Primary = absence of ever having a period when >16 yo
Secondary = Absence of periods for >6months after having previously having periods
What are important features to identify on history for secondary amenorrhoea/oligomenorrhoea?
- Age, contraception, obstetric hx/infertility
- General medical hx, surgical hx, gynaecological problems, Pap smears
- Sexually active? STIs?
- Medications, allergies
- Smoking, alcohol, drugs
- Menstrual hx - age of menarche, LMP (?pregnancy), normal periods (regularity, duration and heaviness of bleeding, pain), how they’ve changed, IMB, PCB
- Hypothalamic causes - stress, unwell, change in weight, increased exercise, diet change
- Endocrine - acne, hirutism, change in bowels, hair/skin/nails, mood, cold intolerance, energy, galactorrhoea, vision change, headaches
- Menopausal symptoms if relevant
- Specific hx autoimmune conditions, thyroid, coeliac disease, cancers/chemoRTx
- FHx - gynaecological problems, clots, CVD, early/premature menopause (what age mother/sisters went through), genetic conditions
What are important features on examination for secondary amenorrhoea/oligomenorrhoea?
Vitals - endocrine
General - body habitus, hair/skin/nails (acne, hirutism, dry skin/hair, brittle nails), nipple discharge
BMI, waist circumference
Eye examination - visual fields
Thyroid examination
Abdominal - tenderness, masses, distention, ascites
Vaginal - external genitalia, tenderness
What are Ix if secondary amenorrhoea/oligomenorrhoea?
Serum B-hCG - exclude pregnancy Mid-luteal phase progesterone Progestin challenge Serum LH/FSH Prolactin TFTs Pelvic U/S PCOS - if indicated
What is a progestin challenge and what does it indicate?
Helps determine if amenorrhoea is due to uterine issue or outlet obstruction
A normal endometrium (with presence of adequate oestrogen) will respond to the withdrawal of progesterone with a withdrawal bleed
Withdrawal bleed therefore means that there is no outflow obstruction/uterine issues and suggests that anovulation is the likely cause of amenorrhoea (i.e. premature ovarian failure or PCOS)
What are the important management issues to consider in amenorrhoea?
Bone health
Oestrogen deficiency symptoms
Infertility
Endometrial hyperplasia/malignancy - lack of progesterone due to anovulation
What is oligomenorrhoea?
Periods which are infrequent (6w-6m apart) and are often irregular in their timing
What are the most common causes of primary cf. secondary amenorrhoea?
Primary >50% ovarian or lower uterine tract
Secondary >75% hypothalamic-pituitary issues
What are the most common causes of secondary amenorrhoea/oligomenorrhoea?
Pregnancy
- PCOS
- Hypogonadotrophic hypogonadism (hypothalamic failure)
- Hyperprolactinaemia
- Ovarian failure - premature menopause
How can FSH/LH levels help classify causes of secondary amenorrhoea?
Central causes (hypothalamic or pituitary) typically lead to LH/FSH - PCOS is exception - FSH will be normal (caused by hyperandrogenism)
Peripheral causes (Ovarian causes) lead to high FSH/LH
What are the causes of primary amenorrhoea?
Most common
- Ovarian - ambiguous genitalia, congenital disorders (Turner’s syndrome, Fragile X carrier)
- Lower genital tract - outlet obstruction i.e. imperforate hyamen, atresias
- Uterine - androgen insensitivity, structural abnormalities
Less common
- Hypothalamic dysfunction
- Hyperprolactinaemia
- Hypothyroidism
- Constitutional delay in puberty
- T1DM
What are important features to identify on history in women with primary amenorrhoea?
- Age
- Exclude pregnancy
- Pubertal status - do they have any current features of normal breast/pelvic development (normal, absent or delayed)
- Lower genital tract causes - abdominal bloating/distention, mass (accumulation of menstrual blood), cyclical pelvic/abdo pain
- Signs of endometriosis (can get this if obstruction leading to severe reflux)
- Endocrine features - PCOS, thyroid, prolactin
- Medical hx - CHD, deafness
Examination for women with primary ameonorrhoea?
If not sexually active - external genitalia examination only for observation of lower genital tract obstruction such as imperforate hyamen
Tanners stages of puberty
Stature - short?
CVD - murmur
Dysmorphic features - i.e. low set ears, webbing of the neck
Management of amenorrhoea?
- Treat reversible causes
- restore weight/weight loss, reduce exercise, stress management
- thyroxine replacement
- Medication optimisation i.e. antipsychotics
- MRI and surgery - prolactinoma - If not desiring fertility currently
- COCP or oestrogen replacement - bone health and prevention of oestrogen deficiency symptoms - If desiring fertility currently
- If ovarian failure cause (high FSH/LH) - donor eggs with IVF
- If central cause (i.e. PCOS) - ovulation stimulation/induction i.e. clomifene (most common), gonadotrophins (FSH) (2nd line - increased risk of multiple pregnancy)
